Diffusion magnetic resonance imaging: A molecular imaging tool caught between hope, hype and the real world of “personalized oncology”

"Personalized oncology" is a multi-disciplinary science, which requires inputs from various streams for optimal patient management. Humongous progress in the treatment modalities available and the increasing need to provide functional information in addition to the morphological data; has led to leaping progress in the field of imaging. Magnetic resonance imaging has undergone tremendous progress with various newer MR techniques providing vital functional information and is becoming the cornerstone of "radiomics/radiogenomics". Diffusionweighted imaging is one such technique which capitalizes on the tendency of water protons to diffuse randomly in a given system. This technique has revolutionized oncological imaging, by giving vital qualitative and quantitative information regarding tumor biology which helps in detection, characterization and post treatment surveillance of the lesions and challenging the notion that "one size fits all". It has been applied at various sites with different clinical experience. We hereby present a brief review of this novel functional imaging tool, with its application in "personalized oncology".

Imaging of the treated breast post breast conservation surgery/oncoplasty: Pictorial review

Mammographic appearance of the normal breast is altered in the post-operative setting. It is essential to be aware of the normal findings as well as to identify features of recurrent disease with particular emphasis on radiologicalpathological concordance. Digital breast tomosynthesis and volumetric breast density add incremental value in this clinical setting. We present a pictorial review of various cases to illustrate normal post-operative findings as well as mammographic features suspicious for recurrent disease.

MRI is a state of art imaging modality in characterization of indeterminate adnexal masses

Aims and Objectives: The aim of this diagnostic observational study was to find an association of final diagnosis of adnexal masses suggested by MRI and compare it as an imaging modality in determining the origin, nature (benign/malignant) & characteristics of adnexal masses by calculating sensitivity, specificity, and diagnostic accuracy. Materials and Methods: The present study was carried out in 90 patients in the department of radio diagnosis and imaging, institute of medical sciences, Banaras Hindu University (BHU). The patients were referred from department of obstetrics & gynecology, institute of medical sciences. Majority of the referred cases were those who had clinical features of abdominal pain, abdominal lump, menstrual irregularity, ascites, and anorexia or weight loss & in whom adnexal mass was suspected clinically. Magnetic resonance imaging was performed using 1.5 Tesla MR Scanner, Magnetom Avanto (Siemens Healthcare). Results: Out of 114 masses, 17 (14.9%) were malignant. The benign adnexal masses were maximum in the age group 20 - 39 years (56/97, 57.7%), while malignant masses were mainly found in women ≥60 years of age (11/17, 64.7%). CA-125 level was grossly elevated in association with 35.3% of the malignant masses. On MRI, the sensitivity for the mass of ovarian origin was (97.7%) and specificity was (73.1%). The diagnostic accuracy was (92.1%). The mass of uterine origin had a sensitivity of (73.1%) and diagnostic accuracy (99.1%). Conclusion: MRI, because of its accuracy in identifying the origin of adnexal mass and characterizing the solid, hemorrhagic, fatty and fibrous content, may obviate surgery or significantly contribute to preoperative planning for a sonographically indeterminate mass. MRI is the state of the art imaging modality for evaluation of adnexal masses with an overall high diagnostic accuracy.

Case of victims of modern imaging technology:Increased information noise concealing the diagnosis

We present a case of tubercular arthritis who underwent numerous unnecessary investigations what is known as "victims of modern imaging technology" or VOMIT. Today there is an exponential rise in the volume of the medical imaging, part of which is contributed by unnecessary and unjustified indications. We discuss about the untoward effects of the uninhibited and careless use of modern imaging modalities and possible ways to avoid. Skeletal manifestation of the tuberculosis is still common in the endemic countries like India. Although the final diagnosis of the skeletal tuberculosis like tubercular arthritis is made by bacteriological and histological studies, few demographic, clinical and radiological features might help making early diagnosis.

Emerging role of computed tomography coronary angiography in evaluation of children with Kawasaki disease

Coronary artery abnormalities are the most important complications in children with Kawasaki disease(KD).Two-dimensional transthoracic echocardiography currently is the standard of care for initial evaluation and follow-up of children with KD.However,it has inherent limitations with regard to evaluation of mid and distal coronary arteries and,left circumflex artery and the poor acoustic window in older children often makes evaluation difficult in this age group.Catheter angiography(CA)is invasive,has high radiation exposure and fails to demonstrate abnormalities beyond lumen.The limitations of echocardiography and CA necessitate the use of an imaging modality that overcomes these problems.In recent years advances in computed tomography technology have enabled explicit evaluation of coronary arteries along their entire course including major branches with optimal and acceptable radiation exposure in children.Computed tomography coronary angiography(CTCA)can be performed during acute as well as convalescent phases of KD.It is likely that CTCA may soon be considered the reference standard imaging modality for evaluation of coronary arteries in children with KD.

Radiation dose analysis of computed tomography coronary angiography in Children with Kawasaki disease

BACKGROUND There is evolving role of computed tomography coronary angiography(CTCA)in non-invasive evaluation of coronary artery abnormalities in children with Kawasaki disease(KD).Despite this,there is lack of data on radiation dose in this group of children undergoing CTCA.AIM To audit the radiation dose of CTCA in children with KD.METHODS Study(December 2013-February 2018)was performed on dual source CT scanner using adaptive prospective electrocardiography-triggering.The dose length product(DLP in milligray-centimeters-mGy.cm)was recorded.Effective radiation dose(millisieverts-mSv)was calculated by applying appropriate age adjusted conversion factors as per recommendations of International Commission on Radiological Protection.Radiation dose was compared across the groups(0-1,1-5,5-10,and>10 years).RESULTS Eighty-five children(71 boys,14 girls)with KD underwent CTCA.The median age was 5 years(range,2 mo-11 years).Median DLP and effective dose was 21 mGy.cm,interquartile ranges(IQR)=15(13,28)and 0.83 mSv,IQR=0.33(0.68,1.01)respectively.Mean DLP increased significantly across the age groups.Mean effective dose in infants(0.63 mSv)was significantly lower than the other age groups(1-5 years 0.85 mSv,5-10 years 1.04 mSv,and>10 years 1.38 mSv)(P<0.05).There was no significant difference in the effective dose between the other groups of children.All the CTCA studies were of diagnostic quality.No child required a repeat examination.CONCLUSION CTCA is feasible with submillisievert radiation dose in most children with KD.Thus,CTCA has the potential to be an important adjunctive imaging modality in children with KD.

Gall bladder carcinoma: Aggressive malignancy with protean loco-regional and distant spread

The most common malignancy of biliary tract is gallbladder cancer(GBC) which is the third most common cancer in gastrointestinal tract. It is a lethal disease for most patients in spite of growing awareness and improved diagnostic techniques. GBC has a verypoor prognosis and the 5 year survival rate is < 10%. Although etiology of the carcinoma of the gallbladder is still obscure, various factors have been implicated, cholelithiasis being the most frequent. The incidence of GBC worldwide is based on the gender, geography and ethnicity which suggest that both genetic and environmental factors can cause GBC. The major route of spread of gallbladder cancer(GC) is locoregional rather than distant. It spreads by lymphatic, vascular, neural, intraperitoneal, and intraductal routes. Sonography is usually the most common imaging test to evaluate symptoms of biliary tract disease including suspected GC. With recent advances in imaging modalities like multi-detector computed tomography(CT) scanners, magnetic resonance imaging-positron emission tomography/CT diagnosis of gallbladder cancer has improved. Studies have also targeted molecular and genetic pathways. Treatment options have included extended and radical surgeries and adjuvant chemotherapy. This review article deals in detail with important aspects of carcinoma gallbladder and its manifestations and challenges. Role of various imaging modalities in characterization and accurate staging has been discussed. The loco-regional spread of this aggressive malignancy is dealt explicitly.

Imaging-based algorithmic approach to gallbladder wall thickening

Gallbladder(GB) wall thickening is a frequent finding caused by a spectrum of conditions. It is observed in many extracholecystic as well as intrinsic GB conditions. GB wall thickening can either be diffuse or focal. Diffuse wall thickening is a secondary occurrence in both extrinsic and intrinsic pathologies of GB, whereas, focal wall thickening is mostly associated with intrinsic GB pathologies. In the absence of specific clinical features, accurate etiological diagnosis can be challenging. The survival rate in GB carcinoma(GBC) can be improved if it is diagnosed at an early stage, especially when the tumor is confined to the wall. The pattern of wall thickening in GBC is often confused with benign diseases, especially chronic cholecystitis, xanthogranulomatous cholecystitis, and adenomyomatosis. Early recognition and differentiation of these conditions can improve the prognosis. In this minireview, the authors describe the patterns of abnormalities on various imaging modalities(conventional as well as advanced) for the diagnosis of GB wall thickening. This paper also illustrates an algorithmic approach for the etiological diagnosis of GB wall thickening and suggests a formatted reporting for GB wall abnormalities.

Imaging in pulmonary hydatid cysts

Hydatid disease is a zoonosis that can involve almost any organ in the human body. After the liver, the lungs are the most common site for hydatid disease in adults. Imaging plays a pivotal role in the diagnosis of the disease, as clinical features are often nonspecific. Classical radiological signs of pulmonary hydatid cysts have been described in the literature, aiding in the diagnosis of the disease. However, complicated hydatid cysts can prove to be a diagnostic challenge at times due to their atypical imaging features. Radiography is the initial imaging modality. Computed tomography can provide a specific diagnosis in complicated cases. Ultrasound is particularly useful in peripheral lung lesions. The role of magnetic resonance imaging largely remains unexplored.

Tight near-total corrosive strictures of the proximal esophagus with concomitant involvement of the hypopharynx: Flexible endoscopic management using a novel technique

AIM To investigate the role of a novel minimally invasive endoscopic technique in the management of tight neartotal corrosive strictures of the proximal esophagus involving the hypopharynx.METHODS Two patients with near-total corrosive strictures of the proximal esophagus involving the hypopharynx were managed with the novel endoscopic technique. The technique involved passing a 0.025-inch flexible guidewire across the stricture, and stricture dilatation, using 10 F coaxial diathermy and balloon dilators, followed byelectro-incision of the proximal aspect of the residual eccentric stricture by means of a novel approach using a wire-guided sphincterotome.RESULTS Both patients were successfully managed on an outpatient department basis with the complete relief of symptoms and resolution of strictures on endoscopy and an esophagogram. No adverse events were seen during or after the procedure. There was no recurrence of symptoms at a follow-up of over a year in both cases. There was a significant improvement in the body mass index of both patients after the procedure.CONCLUSION We report a novel flexible endoscopic technique for the management of complex hypopharyngo-esophageal strictures. In experienced hands, the procedure is relatively simple, safe and effective with a durable response.

Role of Multidetector CT in Evaluation of Polytrauma Patients

Trauma is the leading cause of death in age group less than 45 years. In trauma, time is one of the most crucial factors in predicting prognosis. Outcomes are greatly improved when critical interventions are provided within the golden hour following injury. Whole body multidetector computerised tomography (WBMDCT) can decrease this critical time and increase survival. Emergency CT plays a major role in diagnostic workflow in the evaluation of patients with polytrauma. MDCT scanners are widely used because they rapidly produce high-resolution scans of large areas, offering short examination times for multiple body regions under emergency conditions. Such examinations most often include the head, cervical spine, and thorax to pelvis. Role of MDCT in head trauma remains unparalleled for reasons like its widespread availability and capability to reveal skull fractures, primarily because it is a fast and efficient method to triage the patients with treatable conditions mandating urgent surgical intervention such as extra axial hematomas, mass effect, herniations of brain, hydrocephalus, and midline shift and hence preventing secondary brain injury. MDCT angiography is an important tool to screen patients with suspected vascular injury.

Primary abdominal tuberculosis presenting as peritonitis in a young child-managed surgically

Abdominal tuberculosis(TB) is the sixth commonest extra-pulmonary TB form after lymphatic, genitourinary,bone and joint,miliary and meningeal tuberculosis.We are presenting a rare case in a young female of age 7 year diagnosed as peritonitis and intestinal obstruction.Operative findings revealed dense fibrosis in interloops and perforation of the small bowel.She was put on antitubercular treatment for one year.Patient was discharged in satisfactory condition and is in follow up for 2 months.

Indian patients with nonalcoholic fatty liver disease presenting with raised transaminases are different at presentation

We read with great interest the article, ＂Non-alcoholic fatty liver disease may not be a severe disease at presentation among Asian Indians＂ by Madan et at in the recent issue of WJG. Twenty-eight （55%） out of 51 patients with nonalcoholic fatty liver disease （NAFLD） who presented with abnormal transaminases had histological evidence of nonalcoholic steatohepatitis （NASH）. The majority of patients had grade 1 [32 （63%）] or grade 2 [16 （31%）] inflammation and either had no [23 （45%）] fibrosis or stage I [19 （37%）] fibrosis. None of the patients had cirrhosisf11. We agree with Madan et al that Asian Indians with NAFLD who present with unexplained increase in transaminases may have mild disease at presentation on the basis of similar observations made by us. NAFLD has a spectrum which includes patients with only steatosis and NASH that can progress to cirrhotic and hepatocellular carcinoma.

Multifocal Chest Wall Hamartoma: A Rare Congenital Anomaly

Chest wall hamartoma is a very rare tumour with benign course and distinct clinical, radiological, and histopathological characteristics. The lesion develops during foetal life and is present at or shortly after birth. It should be kept in differential diagnosis of complex chest wall masses diagnosed during antenatal ultrasound. CT thorax is useful for appreciation of detailed anatomy, characterization of the congenital abnormality and for surgical planning. Histopathology is used for the confirmation. Accurate diagnosis of mesenchymal hamartoma is important since many chest wall masses in children are malignant. We report a rare case of multifocal chest wall hamartoma in an infant who presented with multiple bilateral complex chest wall masses in which characteristic radiological and histopathological features led to the diagnosis of hamartoma, which was successfully treated with surgery.

Relief from vascular occlusion using photothermal ablation of tlhrombus with a multimodal perspective

Fibrinolytic therapy for arterial or venous thrombotic disorders involves the systemic administration of thrombolytics such as streptokinase, which is associated with serious bleeding complications. With this study, we provide a proof-of-concept of photothermal thrombus ablation with gold nanorods exposed to near-infrared irradiation, both in vitro using materials generated from purified fibrinogen or plasma and in vivo in murine blood vessels. This is the first report of the application of photothermal therapy as an anti-thrombotic measure. Remarkably, the addition of streptokinase had a multimodal additive effect with regard to acceleration of photothermal lysis of thrombi even at a dose significantly below the therapeutic concentration, thus minimizing the life- threatening side effects and adverse complications. This combinatorial approach exhibits great promise for lysing pathological clots while effectively overcoming the drawbacks of existing therapies.